Ethics and Drug Resistance: Collective Responsibility for Global Public Health

Introduction: Ethics and Drug Resistance
	Background
	Part I: Ethics and Drug-Resistance in Context
	Part II: Theoretical Approaches to Ethics and Drug Resistance
	Part III: Ethics, Regulation, Governance, and Drug Resistance
	Acknowledgments
Contents
Part I: Ethics and Drug Resistance in Context
	Chapter 1: Drug-Resistant Infection: Causes, Consequences, and Responses
		1.1 Introduction
		1.2 Causes
			1.2.1 Evolution and Transmission of Resistance Genes
			1.2.2 Antimicrobial Use in Humans
			1.2.3 Transmission
			1.2.4 Antimicrobial Use in Animals and Agriculture
		1.3 Consequences
			1.3.1 Direct Harms to Human Beings
			1.3.2 Economic Consequences
			1.3.3 Burdensome Public Health Interventions
		1.4 Responses
			1.4.1 New Drugs
			1.4.2 Research and Surveillance
				1.4.2.1 Reducing Use in Humans
				1.4.2.2 Reducing Use in Animals and Agriculture
				1.4.2.3 Addressing Social Determinants of Health
				1.4.2.4 Infection Control
				1.4.2.5 Vaccines
		1.5 Conclusions
		References
	Chapter 2: Preventive Therapy for Multidrug Resistant Latent Tuberculosis Infection: An Ethical Imperative with Ethical Barriers to Implementation?
		2.1 Background
		2.2 Discussion
			2.2.1 Ongoing and Proposed Clinical Trials to Evaluate Antibiotic Therapy to Prevent Drug-Resistant Infection
			2.2.2 Challenges in the Use of Antibiotics as a Research Intervention in LTBI Treatment
				2.2.2.1 How to Balance Between Uncertainties and Risk of Harm: A Common Issue in Public Health Practice
				2.2.2.2 Development of Acquired Drug Resistance during Preventive Therapy
			2.2.3 Challenge in Conducting Research Using Fluoroquinolone in Children
			2.2.4 Poor Understanding about LTBI and the Use of Diagnostic Tests
			2.2.5 Challenges in Obtaining Informed Consent and Following-up Study Participants
			2.2.6 Stigmatization
		2.3 Solutions for Identified Ethical Problems and Challenges
			2.3.1 Developing a Comprehensive LTBI Research Agenda
			2.3.2 Collaboration
			2.3.3 Provide Education and Raise Community Awareness of LTBI
			2.3.4 Strengthen Communication Between Research Ethics Committees (RECs) and Researchers
		2.4 Conclusion
		References
	Chapter 3: Providing Universal Access While Avoiding Antiretroviral Resistance: Ethical Tensions in HIV Treatment
		3.1 Introduction
		3.2 Drug Resistant HIV
		3.3 A Word on HIV Monitoring
		3.4 Key Elements of the ‘Public Health’ Approach to HIV
		3.5 Changes in Eligibility for ART
		3.6 ART in Pregnancy in LMIC: A Case Study
		3.7 Addressing ART Resistance
		3.8 Biomedical Prevention and Drug Resistance
		3.9 Monitoring Drug Resistance Beyond the Individual
		3.10 Conclusion
		References
	Chapter 4: Ethics and Antimalarial Drug Resistance
		4.1 The Problem, Context and Background
			4.1.1 How Should the Problem of Artemisinin Resistant Malaria be Tackled?
		4.2 Practical Ethical Issues Arising in These Interventions
			4.2.1 Ongoing Surveillance
			4.2.2 Mass Drug Administration (MDA)
			4.2.3 Mass Screening and Treatment (MSAT)
			4.2.4 Vector Control
			4.2.5 Targeting ‘Source’ Populations
			4.2.6 Mandatory Screening
			4.2.7 Triple Artemisinin Combination Therapies (TACTs)
		4.3 Summary of Ethical Considerations
			4.3.1 Autonomy and Consent Versus the Global Benefit
			4.3.2 Risk Benefit
			4.3.3 Data and Sample Sharing
			4.3.4 Scientific Disagreement About the Best Way Forward
		4.4 Conclusions
		References
	Chapter 5: Antimicrobial Resistance and the Private Sector in Southeast Asia
		5.1 Diversity, Epidemiology and Surveillance Capacity
		5.2 Private Health Services and AMR
		5.3 Policy Challenges in Tackling AMR
		5.4 Ethical Issues
		5.5 Conclusion
		References
	Chapter 6: Hospital Infection Prevention and Control (IPC) and Antimicrobial Stewardship (AMS): Dual Strategies to Reduce Antibiotic Resistance (ABR) in Hospitals
		6.1 Introduction
		6.2 Hospital Infection in the “Pre-Antibiotic Era”
		6.3 The Antibiotic Era
		6.4 Antibiotic Use and Stewardship in Hospitals
		6.5 Hospital Infection Prevention and Control (IPC) and ABR
			6.5.1 Healthcare-Associated Infections and Their Consequences
			6.5.2 Hospital IPC Programs
			6.5.3 The Central Role of Hand Hygiene in IPC
			6.5.4 Doctors and IPC
			6.5.5 The Organization’s Role in IPC/AMS Programs
		6.6 Conclusions
		References
	Chapter 7: Epidemiology and Ethics of Antimicrobial Resistance in Animals
		7.1 Introduction: Evolutionary History of Antimicrobial Resistance as a Natural Phenomenon
		7.2 Drug Resistance as an Animal or Public Health Concern
		7.3 Antimicrobial Use in Animals
		7.4 Surveillance for Antimicrobial Resistance in Animals
		7.5 Summary and Conclusion
		References
Part II: Theoretical Approaches to Ethics and Drug Resistance
	Chapter 8: The Virtuous Physician and Antimicrobial Prescribing Policy and Practice
		8.1 Antimicrobial Resistance and Virtue Ethics
		8.2 Medical Virtues and Antimicrobial Prescribing
		8.3 Community-Centred Medical Virtues and Antimicrobial Prescribing Practice and Policy
		8.4 Conclusion
		References
	Chapter 9: Moral Responsibility and the Justification of Policies to Preserve Antimicrobial Effectiveness
		9.1 The Problem of Antimicrobial Resistance
		9.2 Public Goods, Tragedy of the Commons, and Policies to Address Antimicrobial Resistance
		9.3 Morality and Antimicrobial Consumption
		9.4 Individual Responsibility and Duty of Easy Rescue: The Ethical Solution to the Tragedy of the Commons and the Responsibilities of the State
		9.5 Conclusions
		References
	Chapter 10: Access to Effective Diagnosis and Treatment for Drug-Resistant Tuberculosis: Deepening the Human Rights-Based Approach
		10.1 Introduction
		10.2 Access to Effective DR-TB Diagnosis and Treatment
		10.3 Rights Based Approach to DR-TB
		10.4 The Right to Enjoy the Benefits of Scientific Progress
			10.4.1 The Obligation to Respect
			10.4.2 The Obligation to Protect
			10.4.3 Obligation to Fulfill
			10.4.4 Realising the REBSP
			10.4.5 Minimum Core Obligations
		10.5 Lack of Scientific Progress in DR-TB
		10.6 Intellectual Property Rights and Access to Essential Medicines
		10.7 Creating an Enabling Environment
		10.8 International Cooperation to Improve Access to DR-TB Drugs
		10.9 Conclusion
		References
	Chapter 11: The Right to Refuse Treatment for Infectious Disease
		11.1 The Right to Refuse Medical Treatment
		11.2 Existing Approaches to Compelled Treatment for Infectious Diseases
		11.3 Ethical Analysis
		References
	Chapter 12: Surveillance and Control of Asymptomatic Carriers of Drug-Resistant Bacteria
		12.1 Introduction
			12.1.1 History
			12.1.2 Against Microbial Determinism
			12.1.3 Key Drug-Resistant Pathogens
		12.2 The Public Health Problem
			12.2.1 Antibiotic Use and Drug Resistance
			12.2.2 Transmission
			12.2.3 Duration of Carriage
		12.3 Potential Public Health Responses
			12.3.1 Surveillance, Notification, and Monitoring
			12.3.2 Restrictions of Freedom of Movement (Isolation, Quarantine, Travel Bans)
			12.3.3 Treatment and Decolonization
		12.4 Ethical Issues
			12.4.1 Applying Public Health Ethics Frameworks
			12.4.2 Public Health Intervention for Healthy Carriers
			12.4.3 Burdens of Interventions and Support for Carriers
		12.5 The Need for More Surveillance and Research
		12.6 Conclusions
		References
	Chapter 13: Conceptualizing the Impact of MDRO Control Measures Directed at Carriers: A Capability Approach
		13.1 Introduction
		13.2 The Ethical Treatment of MDRO Carriers: A Neglected Issue
		13.3 A Capabilitarian Framework for Conceptualizing the Impact of MDRO Control Measures
		13.4 Nussbaum’s Ten Central Capabilities: A Starting Point
		13.5 A Taxonomy of Normatively Relevant Capabilities in the Context of Addressing MDRO Carriership
		13.6 Applying the Capabilitarian Taxonomy in Practice
		13.7 Concluding Remarks
		References
	Chapter 14: A Capability Perspective on Antibiotic Resistance, Inequality, and Child Development
		14.1 Introduction
		14.2 Capability Theory
		14.3 Infectious Disease and Capabilities
		14.4 Human Dignity and Infectious Disease
		14.5 Clustering of Disadvantage: The Example of Growth Stunting
		14.6 Capability Thresholds and Inequality?
		14.7 International Cooperation, Unequal Partners
		14.8 A Relational Approach to Capability Inequality
		14.9 Inequalities Subvert Capabilities
		14.10 Addressing Inequalities, Achieving Capability Thresholds
		14.11 Conclusions
		References
	Chapter 15: Fairness in the Use of Information About Carriers of Resistant Infections
		15.1 The Important Roles of Information
		15.2 The Vector Perspective
		15.3 The Victim Perspective
		15.4 Fairness in Information Use
		References
	Chapter 16: Antimicrobial Resistance and Social Inequalities in Health: Considerations of Justice
		16.1 Introduction
		16.2 Health Inequalities and Health Egalitarianism: Definitions
			16.2.1 Toward a Multi-dimensional Account of Justice, Health, and Equality as a Normative Goal
		16.3 Examples
			16.3.1 Example: AMR, Sex, and Gender
			16.3.2 Example: AMR and Parasitic Infection
			16.3.3 Summary of Examples
		16.4 Health Inequalities: The Development Narrative
			16.4.1 Is the Development Narrative True?
			16.4.2 Underlying Realities
			16.4.3 Underlying Causes
			16.4.4 Implications for Global AMR Policy
			16.4.5 AMR and Widening Within-Country Social Inequality in Health
		16.5 Conclusion
		References
	Chapter 17: The Economics of Resistance Through an Ethical Lens
		17.1 Introduction
		17.2 Antimicrobial Resistance and ‘The Market’
			17.2.1 Externalities
			17.2.2 Public Goods
		17.3 The Ethics and Economics of Demand
			17.3.1 Free-Riding by Consumers
			17.3.2 Free-Riding Across Nations
			17.3.3 Time Preference and Discounting: Free-Riding Across Time
			17.3.4 The Importance of Context
		17.4 The Ethics and Economics of Supply
			17.4.1 Free-Riding and Intellectual Property
			17.4.2 Alternative Systems
		17.5 Discussion: The Convergence of Ethics and Economics
		References
Part III: Ethics, Regulation, Governance, and Drug Resistance
	Chapter 18: Antibiotics and Animal Agriculture: The Need for Global Collective Action
		18.1 Introduction
		18.2 Economic Models
			18.2.1 Prisoner’s Dilemma
			18.2.2 Tragedy of the Commons
			18.2.3 Public Goods
		18.3 Moral Principles
		18.4 Global Coordination
		References
	Chapter 19: Technological Fixes and Antimicrobial Resistance
		19.1 Introduction
		19.2 Technological Fixes
		19.3 Technological Fixes and Health
		19.4 Technological Fixes in the Context of Antimicrobial Resistance
		19.5 Technological Fixes and Distributive Justice
		References
	Chapter 20: Tackling Anti-microbial Resistance: An Ethical Framework for Rational Antibiotic Use
		20.1 Introduction
		20.2 Rational Use of Antibiotics
		20.3 Ethically Challenging Instances of Rational Use
		20.4 The Analogy to Clinical Research
		20.5 An Ethical Framework for Evaluating Rational Antibiotic Use
		20.6 Potential Objections
		20.7 Conclusion
		Appendix: Ethical Framework for Rational Antibiotic Use
		References
	Chapter 21: Solidarity and Antimicrobial Resistance
		21.1 Introduction
		21.2 Solidarity and Public Health
		21.3 Solidarity and Antimicrobial Resistance
		21.4 Solidarity as a Motivational Factor
		21.5 The Extent and Limitations of Solidarity
		21.6 Conclusion
		References
	Chapter 22: Justifying Antibiotic Resistance Interventions: Uncertainty, Precaution and Ethics
		22.1 Antibiotic Resistance
		22.2 Precaution
		22.3 Evidence
		22.4 Justifying Interventions
			22.4.1 Biomedical Interventions
			22.4.2 Prescription Practices
			22.4.3 Surveillance
			22.4.4 Environment and Animals
		22.5 Discussion
	Chapter 23: Antimicrobial Footprints, Fairness, and Collective Harm
		23.1 Introduction
		23.2 Antimicrobial Resistance as a Collective Moral Action Problem
		23.3 Antimicrobial Footprints
		23.4 The Argument from Unfairness
		23.5 The Collective Harm Argument
		23.6 Conclusion
		References
	Chapter 24: Global Health Governance and Antimicrobial Resistance
		24.1 Introduction
		24.2 The Rise of Drug Resistance
		24.3 A Global Approach to AMR?
		24.4 The International Health Regulations, Global Health Governance and AMR
		24.5 Building Capacity
		24.6 Understandings and Definitions
		24.7 AMR and the Sustainable Development Goals (SDGs)
		24.8 Conclusion
		References
	Chapter 25: Global Governance of Anti-microbial Resistance: A Legal and Regulatory Toolkit
		25.1 Introduction
		25.2 The WHO and AMR
			25.2.1 Collective Action Problem
			25.2.2 Global Action Plan
			25.2.3 Limitations of the Global Action Plan
		25.3 Regulatory Leverage for Responsible Use and Good Stewardship of Antimicrobials
			25.3.1 Ensuring Quality
			25.3.2 Improving Prescribing and Dispensing
			25.3.3 Ensuring Appropriate, Affordable and Equitable Access
		25.4 Regulatory Lever Within a Whole-of-System Approach
			25.4.1 Financial Lever
			25.4.2 Information Lever
		25.5 Conclusion
		References
	Chapter 26: The Super-Wicked Problem of Antimicrobial Resistance
		26.1 Challenges in Responding to AMR
		26.2 Framing AMR as a Super-Wicked Problem
			26.2.1 Criterion 1: Time Is Running Out
			26.2.2 Criterion 2: Those Seeking a Solution Are Part of the Problem
			26.2.3 Criterion 3: Central Authorities to Address the Problem Are either Weak or Non-existent
			26.2.4 Criterion 4: Current Policies Discount the Future Irrationally
		26.3 How Conceptualizing AMR as a Super-Wicked Problem Can Inform Policy Making
		26.4 Incrementally Creating Transformative Shifts in Path Dependency: Alternative Strategies
			26.4.1 Authoritative Strategies
			26.4.2 Competitive Strategies
			26.4.3 Collaborative Strategies
		26.5 Shifting Path Dependencies – The Way Forward
		26.6 Conclusion
Index